Project Summary/Abstract Skilled nursing facility (SNF) patients are medically complex with incurable chronic conditions, dependence on caregivers for activities of daily living, and recent acute illness, such as septicemia and hip and femur procedures. Despite the high prevalence of acute care use and mortality after SNF patients return home (>50% in 90 days), SNF patients and their caregivers do not receive transitional care that prepares them to self-manage the patient?s serious illness and achieve the patient?s health care goals at home. No efficacy studies of transitional care have targeted this population, or measured whether interventions resulted in improved patient and caregiver outcomes. The proposed project will test the efficacy of Connect-Home, a successfully piloted transitional care intervention, targeting seriously ill SNF patients who discharge to home and their caregivers. The study will be set in six North Carolina SNFs and, during intervention periods, also in the patient?s home. Using a stepped-wedge cluster-randomized trial design, six SNFs will be randomly allocated to standard discharge planning vs. the Connect-Home intervention over six sequential time-periods. All SNFs will contribute data for patients (N=360) and their caregivers (N=360), who will receive standard discharge planning or Connect-Home in the SNF at the time of the patient?s enrollment. Connect-Home is a two-step transitional care intervention: 1) creation of the Transition Plan of Care in the SNF, and 2) a supportive Nurse Home Visit in 24 hours of discharge. Both of these steps focus on preparing the patient and caregiver for self-care for serious illness at home in 5 clinical domains?medication reconciliation, reinforcement of the Transition Plan of Care, coaching for outpatient medical follow-up, fall safety assessment, and review of advance directives and goals of care. Existing SNF and home health staff will deliver the intervention. To be eligible, patients must discharge home, speak English, require at least 25-50% assistance for mobility, be diagnosed with a serious medical condition, and must not have planned hospital readmission in next 90 days. To be eligible caregivers must assist the patient at home and have the ability to speak English. We will assess patient and caregiver outcomes: (a) in 7 days after discharge, we will assess patient and caregiver preparedness for discharge using the Care Transitions Measure-15 (primary outcome); and, (b) in 30 and 60 days after discharge, we will assess patient quality of life, function, falls, days of acute care use and caregiver burden and distress (secondary outcomes). We will use hierarchical linear models (HLM) to compare observations between intervention and usual care periods for our primary outcome. Results of this study will demonstrate the potential efficacy of an innovative intervention to improve transitional care for seriously ill SNF patients, (b) prevent avoidable days of acute care use in a population with persistent risks related to serious illness, and (c) extend transitional care science by testing the efficacy of transitional care for vulnerable SNF patients and their caregivers.